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Head & Neck Apr 2020Prophylactic arterial ligation has been proposed to reduce the severity of postoperative hemorrhage following transoral robotic surgery (TORS). Previous studies have... (Meta-Analysis)
Meta-Analysis Review
Prophylactic arterial ligation has been proposed to reduce the severity of postoperative hemorrhage following transoral robotic surgery (TORS). Previous studies have shown a trend toward a reduction in major and severe bleeding. Search strategies were implemented in multiple databases and completed in August 2018. Inclusion and exclusion criteria were designed to capture studies examining adults undergoing TORS for oropharyngeal cancer. Four retrospective studies were selected appropriate for analysis by two reviewers who independently extracted data. PRISMA guidelines were followed. A random-effects model was used for meta-analysis. Meta-analysis of 619 patients in four retrospective reviews showed that the pooled RR of major and severe bleeding events was significantly lower in prophylactically ligated patients (RR, 0.28; 95% CI, 0.08-0.92; I = 0). Prophylactic arterial ligation of external carotid artery branches is associated with a decreased risk of major and severe bleeding events, although confounding factors remain incompletely analyzed.
Topics: Adult; Humans; Ligation; Oropharyngeal Neoplasms; Postoperative Hemorrhage; Retrospective Studies; Robotic Surgical Procedures
PubMed: 31778006
DOI: 10.1002/hed.26020 -
The Cochrane Database of Systematic... Dec 2012This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008 and previously updated in 2010.Tonsillectomy continues to be one of the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008 and previously updated in 2010.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.
OBJECTIVES
To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.
SEARCH METHODS
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 20 March 2012.
SELECTION CRITERIA
All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.
DATA COLLECTION AND ANALYSIS
Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models.
MAIN RESULTS
Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (risk ratio (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of patients with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).
AUTHORS' CONCLUSIONS
The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). The limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence, therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.
Topics: Adult; Analgesics; Anti-Bacterial Agents; Antibiotic Prophylaxis; Bacterial Infections; Child; Convalescence; Fever; Humans; Pain, Postoperative; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Tonsillectomy
PubMed: 23235625
DOI: 10.1002/14651858.CD005607.pub4 -
Journal of Laparoendoscopic & Advanced... Apr 2017To compare intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) in laparoscopic right colectomy (LRC) in terms of intraoperative and postoperative... (Comparative Study)
Comparative Study Meta-Analysis Review
AIM
To compare intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) in laparoscopic right colectomy (LRC) in terms of intraoperative and postoperative outcomes.
METHODS
A systematic literature search with no limits was performed in PubMed and Embase. The last search was performed on April 9, 2016. The outcomes of interests included intraoperative outcomes (operative time, blood loss, length of incision, conversion, lymph nodes harvested, and intraoperative complications) and postoperative outcomes (time to first flatus, time to first defecation, time to liquid diet, length of hospital stay, postoperative complications, mortality, ileus, anastomotic leakage, anastomotic bleeding, wound infection, hernia, and intra-abdominal abscess).
RESULTS
Fifteen articles and four conference abstracts published between 2004 and 2016 with a total of 1957 patients were enrolled in this meta-analysis. IA was associated with significant less blood loss, smaller length of incision, shorter time to first defecation, shorter time to liquid diet, and shorter length of hospital stay. No differences were found for operative time, conversion, lymph nodes harvested, intraoperative complications, time to first flatus, postoperative complications, mortality, anastomotic leakage, anastomotic bleeding, ileus, wound infection, intra-abdominal abscess, or hernia between IA and EA.
CONCLUSION
Our meta-analysis suggests that the IA for LRC improves cosmesis and results in better postoperative recovery outcomes without increasing intraoperative and postoperative complications. Furthermore, a large randomized control study is warranted to compare the short-term and long-term outcomes of those two anastomosis techniques.
Topics: Abdominal Abscess; Anastomosis, Surgical; Anastomotic Leak; Colectomy; Colon, Ascending; Humans; Ileus; Intraoperative Complications; Laparoscopy; Length of Stay; Lymph Node Excision; Lymph Nodes; Operative Time; Postoperative Complications; Postoperative Hemorrhage; Postoperative Period; Surgical Wound Infection; Treatment Outcome
PubMed: 27768552
DOI: 10.1089/lap.2016.0485 -
Journal of Clinical Anesthesia Aug 2020Low level of fibrinogen is a risk factor of perioperative bleeding, which is a major complication in surgical patients. However, the safety and efficacy of fibrinogen... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Low level of fibrinogen is a risk factor of perioperative bleeding, which is a major complication in surgical patients. However, the safety and efficacy of fibrinogen supplementation with fibrinogen concentrate to minimize postoperative bleeding remains unclear.
OBJECTIVES
The primary aim of this review was to investigate the effect of fibrinogen concentrate in postoperative blood loss in adult surgical patients.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
Databases of MEDLINE, EMBASE and CENTRAL were searched from their start date until July 2019.
ELIGIBILITY CRITERIA
All randomized clinical trials comparing intravenous fibrinogen concentrate and placebo in adult surgical patients were included, regardless of type of surgery. Observational studies, case reports, case series and non-systematic reviews were excluded.
RESULTS
Thirteen trials (n = 900) were included in this review. In comparison to placebo, fibrinogen concentrate significantly reduced the first 12-hour postoperative blood loss, with a mean difference of -134.6 ml (95% CI -181.9 to -87.4). It also significantly increased clot firmness in thromboelastometry (FIBTEM) with a mean difference of 2.5 mm (95%CI 1.1 to 3.8). No significant differences were demonstrated in the adverse events associated with fibrinogen concentrate use, namely incidence of thromboembolism, myocardial infarction and acute kidney injury.
CONCLUSIONS
In this meta-analysis of 13 randomized trials, low level of evidence and substantial heterogeneity with small sample size limit strong recommendation on the use of fibrinogen concentrate in adult surgical patients. However, its use is tolerable without any notable adverse events.
TRIAL REGISTRATION
CRD42019149164.
Topics: Adult; Fibrinogen; Hemostatics; Humans; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Thrombelastography
PubMed: 32193125
DOI: 10.1016/j.jclinane.2020.109782 -
The Annals of Thoracic Surgery Feb 2006The optimal approach to early postoperative anticoagulation after mechanical valve implantation remains controversial. This review article examines the pathogenesis of... (Review)
Review
The optimal approach to early postoperative anticoagulation after mechanical valve implantation remains controversial. This review article examines the pathogenesis of thrombus formation and the different strategies for early postoperative anticoagulation. The most commonly reported anticoagulation regimens had the after estimates of early postoperative thromboembolism and hemorrhage: oral anticoagulation alone (0.9%, 3.3%); oral anticoagulation with intravenous unfractionated heparin (1.1%, 7.2%); and oral anticoagulation with low molecular weight heparin (0.6%, 4.8%). Although intravenous heparin may be associated with a higher incidence of hemorrhage, a randomized trial is needed to provide the best evidence regarding early postoperative anticoagulation after mechanical valve implantation. Nearly four decades have passed since the first mechanical prosthetic valves were implanted. Frequent thromboembolic complications with the first mechanical valves led to recommendations of universal anticoagulation for these patients. Since then, several design changes and modifications have been made to improve the longevity, hemodynamics, and thrombogenicity of newer generation mechanical valves. With improved blood flow, less stasis, and less thrombogenic materials, lower rates of thromboembolism have been reported. Despite these advances however, thromboembolism and anticoagulant-related bleeding continue to account for 75% of all complications after mechanical valve replacement. Occurring most commonly within six months after implantation, these complications can adversely affect mortality and quality of life. Furthermore, the threat of their occurrence creates a psychological burden for each patient with a mechanical valve. The need for life-long anticoagulation in patients with mechanical valves is not in dispute, and the perioperative management of anticoagulation during non-cardiac surgery has been reviewed extensively. However, the approach to early postoperative anticoagulation after mechanical valve implantation is still a matter of debate. The optimal intensity and timing of anticoagulation to prevent early thromboembolism after valve replacement surgery without postoperative bleeding complications is unknown. Hence, many anticoagulation protocols have been proposed, but a lack of consensus remains. The objectives of this study were (1) to reexamine the pathogenesis of thrombus formation and the need for anticoagulation; (2) to critically review the literature on early postoperative anticoagulation strategies; and (3) provide an estimate of the incidence of bleeding and thromboembolism for each approach to early postoperative anticoagulation.
Topics: Administration, Oral; Anticoagulants; Drug Therapy, Combination; Heart Valve Prosthesis Implantation; Hemorrhage; Heparin; Humans; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Risk Factors; Thromboembolism; Warfarin
PubMed: 16427905
DOI: 10.1016/j.athoracsur.2005.07.023 -
Periodontology 2000 Oct 2014A transalveolar approach for sinus floor elevation with subsequent placement of dental implants was first suggested by Tatum in 1986. In 1994, Summers described a... (Review)
Review
A transalveolar approach for sinus floor elevation with subsequent placement of dental implants was first suggested by Tatum in 1986. In 1994, Summers described a different transalveolar approach using a set of tapered osteotomes with increasing diameters. The transalveolar approach of sinus floor elevation, also referred to as 'osteotome sinus floor elevation', the 'Summers technique' or the 'Crestal approach', may be considered as being more conservative and less invasive than the conventional lateral window approach. This is reflected by the fact that more than nine out of 10 patients who experienced the surgical procedure would be willing to undergo it again. The main indication for transalveolar sinus floor elevation is reduced residual bone height, which does not allow standard implant placement. Contraindications for transalveolar sinus floor elevation may be intra-oral, local or medical. The surgical approach utilized over the last two decades is the technique described by Summers, with or without minor modifications. The surgical care after implant placement using the osteotome technique is similar to the surgical care after standard implant placement. The patients are usually advised to take antibiotic prophylaxis and to utilize antiseptic rinses. The main complications reported after performing a transalveolar sinus floor elevation were perforation of the Schneiderian membrane in 3.8% of patients and postoperative infections in 0.8% of patients. Other complications reported were postoperative hemorrhage, nasal bleeding, blocked nose, hematomas and benign paroxysmal positional vertigo. Whether it is necessary to use grafting material to maintain space for new bone formation after elevating the sinus membrane utilizing the osteotome technique is still controversial. Positive outcomes have been reported with and without using grafting material. A prospective study, evaluating both approaches, concluded that significantly more bone gain was seen when grafting material was used (4.1 mm mean bone gain compared with 1.7 mm when no grafting material was utilized). In a systematic review, including 19 studies reporting on 4388 implants inserted using the transalveolar sinus floor elevation technique, the 3-year implant survival rate was 92.8% (95% confidence interval: 87.4-96.0%). Furthermore, a subject-based analysis of the same material revealed an annual failure rate of 3.7%. Hence, one in 10 subjects experienced implant loss over 3 years. Several of the included studies demonstrated that transalveolar sinus floor elevation was most predictable when the residual alveolar bone height was ≥ 5 mm and the sinus floor anatomy was relatively flat.
Topics: Alveolar Process; Bone Substitutes; Contraindications; Dental Implants; Humans; Nasal Mucosa; Osteotomy; Postoperative Complications; Sinus Floor Augmentation; Survival Analysis
PubMed: 25123761
DOI: 10.1111/prd.12043 -
The American Journal of Gastroenterology Aug 2016Many studies around the world addressed the post-colonoscopy complications, but their pooled prevalence and time trends are unknown. We performed a systematic review and... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Many studies around the world addressed the post-colonoscopy complications, but their pooled prevalence and time trends are unknown. We performed a systematic review and meta-analysis of population-based studies to examine the pooled prevalence of post-colonoscopy complications ("perforation", "bleeding", and "mortality"), stratified by colonoscopy indication. Temporal variability in the complication rate was assessed.
METHODS
We queried Pubmed, Embase, and the Cochrane library for population-based studies examining post-colonoscopy complications (within 30 days), performed from 2001 to 2015 and published by 1 December 2015. We determined pooled prevalence of perforations, post-colonoscopy bleeding, post-polypectomy bleeding, and mortality.
RESULTS
We retrieved 1,074 studies, of which 21 met the inclusion criteria. Overall, pooled prevalences for perforation, post-colonoscopy bleeding, and mortality were 0.5/1,000 (95% confidence interval (CI) 0.4-0.7), 2.6/1,000 (95% CI 1.7-3.7), and 2.9/100,000 (95% CI 1.1-5.5) colonoscopies. Colonoscopy with polypectomy was associated with a perforation rate of 0.8/1,000 (95% CI 0.6-1.0) and a post-polypectomy bleeding rate of 9.8/1,000 (95% CI 7.7-12.1). Complication rate was lower for screening/surveillance than for diagnostic examinations. Time-trend analysis showed that post-colonoscopy bleeding declined from 6.4 to 1.0/1,000 colonoscopies, whereas the perforation and mortality rates remained stable from 2001 to 2015. Overall, considerable heterogeneity was observed in most of the analyses.
CONCLUSIONS
Worldwide, the post-colonoscopy complication rate remained stable or even declined over the past 15 years. The findings of this meta-analysis encourage continued efforts to achieve and maintain safety targets in colonoscopy practice.
Topics: Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Gastrointestinal Hemorrhage; Humans; Intestinal Perforation; Mortality; Postoperative Complications; Postoperative Hemorrhage; Prevalence; Time Factors
PubMed: 27296945
DOI: 10.1038/ajg.2016.234 -
Journal of Gastrointestinal Surgery :... Apr 2013Fibrin sealants are frequently used in liver surgery to achieve intraoperative haemostasis and reduce post-operative haemorrhage and bile leak. This meta-analysis aimed... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Fibrin sealants are frequently used in liver surgery to achieve intraoperative haemostasis and reduce post-operative haemorrhage and bile leak. This meta-analysis aimed to review the haemostatic and biliostatic capacity of fibrin sealants in elective liver surgery.
METHODS
An electronic search was performed on the MEDLINE, Embase and PubMed databases using both subject headings and truncated word searches to identify all published articles that are related to this topic. Pooled risk ratios were calculated for categorical outcomes, and mean differences for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis.
RESULTS
Ten randomised controlled trials encompassing 1,225 patients were analysed to achieve a summated outcome. Pooled data analysis showed the use of fibrin sealants resulted in reduced time to haemostasis (mean difference -3.45 min [-3.78, -3.13] (P < 0.00001)) and increased numbers of patients with complete haemostasis (risk ratio 1.56, 95 % confidence interval 1.04-2.34, p = 0.03) when compared to controls. The use of fibrin sealants did not influence perioperative blood transfusion requirements, bile leak rates, post-operative haemorrhage, intra-abdominal collections and overall morbidity and mortality compared with controls.
CONCLUSIONS
There is no solid evidence that the routine use of fibrin sealants reduces the incidence of post-operative haemorrhage or bile leak compared with other treatments. The use of fibrin sealants may reduce the time to haemostasis, but this does not translate to improved perioperative outcomes.
Topics: Bile; Elective Surgical Procedures; Fibrin Tissue Adhesive; Hemostatic Techniques; Hemostatics; Hepatectomy; Humans; Postoperative Complications; Postoperative Hemorrhage
PubMed: 23086450
DOI: 10.1007/s11605-012-2055-7 -
The Journal of Vascular Access 2016Surgical arteriovenous fistula (AVF) or graft (AVG) is preferred to a central venous catheter for dialysis access. Surgical access may suffer thrombosis early after... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Surgical arteriovenous fistula (AVF) or graft (AVG) is preferred to a central venous catheter for dialysis access. Surgical access may suffer thrombosis early after placement and systemic anticoagulation during surgical access formation may increase patency rates but would be expected to increase bleeding-related complications. A systematic review and meta-analysis of randomised controlled trials was conducted to examine the impact of systemic anticoagulation on access surgery perioperative bleeding and patency rates.
METHODS
We included randomised controlled trials testing systemic anticoagulation during access formation versus a control group without systemic anticoagulation reporting bleeding complications and access patency. Medline, Embase, CENTRAL and CINAHL were searched up to March 2015. Risk of bias was assessed using the Cochrane risk of bias tool and the Jadad score. Meta-analysis was performed using Cochrane Revman® software.
RESULTS
Searches identified 445 reports of which four randomised studies involving 411 participants were included. Three studies pertained to AVF only and one included both AVF and AVG. Systemic anticoagulation led to increased bleeding events in all access [four trials; risk ratio (RR) 7.18; confidence interval (CI), 2.41 to 21.38; p<0.001]. Patency was not improved for all access (four trials; RR, 0.64; CI, 0.37 to 1.09; p = 0.10) but was improved when AVF analysed alone (three trials; RR, 0.57; CI, 0.33 to 0.97; p = 0.04).
CONCLUSIONS
The use of intraoperative systemic anticoagulation during access formation is associated with a highly significant increased risk of bleeding-related complications. A significant improvement in AVF patency was seen, though not when AVF and AVG were analysed together.
Topics: Anticoagulants; Arteriovenous Shunt, Surgical; Blood Loss, Surgical; Blood Vessel Prosthesis Implantation; Chi-Square Distribution; Drug Administration Schedule; Graft Occlusion, Vascular; Humans; Intraoperative Care; Odds Ratio; Postoperative Hemorrhage; Renal Dialysis; Risk Factors; Thrombosis; Treatment Outcome; Vascular Patency
PubMed: 26660043
DOI: 10.5301/jva.5000484 -
Spine Apr 2010Systematic review. (Review)
Review
STUDY DESIGN
Systematic review.
OBJECTIVE
To determine the high-risk populations for thromboembolic events in spine surgery patients, the risk of anticoagulation in spine surgery patients by type of anticoagulation, and whether there is a safe perioperative window of nonanticoagulation for these high-risk patients.
SUMMARY OF BACKGROUND DATA
Thromboembolic complications after major spinal surgery is a significant risk for patients. Anticoagulation to reduce this risk is of concern because of the possibility of excessive bleeding or postoperative hematomas and associated neurologic deficits. There seems to be a paucity of literature on this topic.
METHODS
A systematic review of the English-language literature was undertaken for articles published between January 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining coagulopathy in major spine surgery. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria, assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus.
RESULTS
A total of 93 articles were initially screened, and 29 ultimately met the predetermined inclusion criteria. The risk of thromboembolism in patients not receiving chemical prophylaxis was slightly higher in surgery to correct deformity (5.3%) and trauma patients (6.0%) than in surgery for degenerative conditions (2.3%). Fatal pulmonary embolism was rare. Bleeding complications occurred rarely with the use of anticoagulation; risk of major bleeding ranged from 0.0% to 4.3% across several types of anticoagulants. Postoperative hematoma was reported in only 10 of 2507 patients.
CONCLUSION
Venous thromboembolism is uncommon after elective spine surgery. Trauma patients are at increased risk, and chemical prophylaxis should be considered. The safe timing of the administration of anticoagulation agents is unknown.
Topics: Anticoagulants; Humans; Incidence; Neurosurgical Procedures; Postoperative Complications; Postoperative Hemorrhage; Risk Assessment; Spinal Diseases; Thromboembolism; Wounds and Injuries
PubMed: 20407343
DOI: 10.1097/BRS.0b013e3181d833d4